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Nursing Complex Care Exam 1 Study Guide, Exams of Nursing

Cambridge Technical InstituteNursing

Nursing Complex Care Exam 1 Study Guide

Typology: Exams

2024/2025

Available from 09/10/2024

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Nursing Complex Care Exam 1 Study Guide
1.What is priority nursing care for Low Pressure Alarms?: tubing
disconnection extubation
cuff tube/leak
2.What is priority nursing care for High Pressure Alarms?: secretions,
cough- ing, gagging
pt fighting vent
condensation in
tube kinked/biting
tube
increased resistance (bronchospasm)
decreased compliance (pulm. edema, pneumothorax)
3.What are the clinical indications for Mechanical Ventilation?:
Apnea Acute respiratory failure
Severe Hypoxia
Respiratory muscle
fatigue
PEEP = ARDS (pushing air end
exhale) PSV = weening (pushes air
w/ inhale)
4.What are complications of Positive Pressure Ventilation?: Barotrauma -
air escapes alveoli causing pneumothorax (collapse lung)
Pneumomediatinum - ruptured alveoli, air to mediastinum or neck;
pneumothorax Volutrauma - large Vt, noncompliant lungs, fluid in
alveolar space
VAP - pneumonia 48hrs after intubation
5.How do you prevent VAP?: HOB
elevation no routine changes of
ventilator tubing continuous subglottic
suction
strict hand hygiene
drain water from
tubing
always wear gloves and change gloves between activities
6.How do you prevent Aspiration?: HOB
elevated suction mouth frequently
maintain proper cuff inflation (20-25 cm H20)
7.How do you prevent Suctioning Complications?: assess pt before,
during, & after
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Nursing Complex Care Exam 1 Study Guide

  1. What is priority nursing care for Low Pressure Alarms?: tubing disconnection extubation cuff tube/leak
  2. What is priority nursing care for High Pressure Alarms?: secretions, cough- ing, gagging pt fighting vent condensation in tube kinked/biting tube increased resistance (bronchospasm) decreased compliance (pulm. edema, pneumothorax)
  3. What are the clinical indications for Mechanical Ventilation?: Apnea Acute respiratory failure Severe Hypoxia Respiratory muscle fatigue PEEP = ARDS (pushing air end exhale) PSV = weening (pushes air w/ inhale)
  4. What are complications of Positive Pressure Ventilation?: Barotrauma - air escapes alveoli causing pneumothorax (collapse lung) Pneumomediatinum - ruptured alveoli, air to mediastinum or neck; pneumothorax Volutrauma - large Vt, noncompliant lungs, fluid in alveolar space VAP - pneumonia 48hrs after intubation
  5. How do you prevent VAP?: HOB elevation no routine changes of ventilator tubing continuous subglottic suction strict hand hygiene drain water from tubing always wear gloves and change gloves between activities
  6. How do you prevent Aspiration?: HOB elevated suction mouth frequently maintain proper cuff inflation (20-25 cm H20)
  7. How do you prevent Suctioning Complications?: assess pt before, during, & after

hyperoxygenate before & after each pass (30sec) limit pass to 10 sec assess SPO2 and ECG use 100- 120mmHg use aseptic technique

  1. How is ET tube placement confirmed?: chest x-ray end-tidal CO2 detector (exhaled CO2) color change or number auscultate bilateral LS and epigastrium observe symmetric chest mvmt SPO2 improvement
  2. How is ET tube placement Evaluated?: ABGs end tidal CO2 monitoring SPO2 monitoring
  3. How do you maintain ET tube placement?: place an exit mark on tube confirm mark remains constant observe symmetrical chest wall mvmt auscultate bilateral LS
  4. How do you know when a ventilator pt is ready to wean?: pt able to breath spontaneously muscle strength & endurance clear LS clear x-ray hemodynamically stable pt able to initiate inspiration adequate oxygenation awake and alert
  5. How do you manage Psychosocial need for Vent pts?: make them feel safe give information encourage hope build trust involve pts in decisions (control) assess delirium administer sedation & analgesia together & monitor assess train of four (peripheral nerve stimulation, 1-2 twitches),
  1. What is emergency care for Extubation?: Observe for signs: pt talking, low pressure alarm, absent LS, respiratory distress, gastric distention Stay w/ pt Call for help Maintain airway: BVM 100% O Secure assistance in immediate reintubation
  2. What is emergency care if the Mechanical Ventilator fails?: disconnect from machine manually ventilate (BVM 100% O2) wait for vent to be fix or replaced
  3. What is normal range for MAP?: 70-105mmHg
  4. What is normal range for CVP (central venous pressure)?: 2-8 mmHG (R side filling)
  5. What is normal range for PAWP (pulmonary artery wedge pressure)?: 6- 12 mmHg (L. Vent. function)
  6. What does Low MAP mean?: Decreased blood flow to the organs/decreased afterload
  7. What does high MAP mean?: Increased cardiac workload
  8. What does low CVP mean?: hypovolemia needs fluids
  9. What does high CVP mean?: fluid overload right sided HF needs diuresis
  10. What does low PAWP mean?: Hypovolemia
  11. What does high PAWP mean?: Left ventricular failure
  12. What are the CM of decreased CO?: pallor/cool skin diminished pulses change LOC decreased UO hypoactive/absent bowel sounds tachycardia delayed cap refill signs of HF (fatigue, crackles, dyspnea, JVD, cough, edema)
  13. What are indications for a Circulatory Assist Device?: unstable angina short term till heart transplant

acute MI cardiogenic shock pre/intra/postoperative cardiac surgery

Monitor for S/S of infection Change tubing & bag q 96hrs Perform Allen test (check radial/ulnar arteries)

Maintain pressure bag Check distal to site for neurovascular

  1. How do you position the Zero Reference Stopcock (arterial lines)?: mark phlebostatic axis on chest (4th intercostal/midchest) recheck the level of zero reference stopcock to phlebostatic axis w/ change in position high placement = low readings low placement = high readings
  2. What is Cardiogenic Shock?: Systolic or Diastolic dysfunction (MI, HF, etc) that causes decreased CO.
  3. What are CM of Cardiogenic Shock?: tachycardia hypotension tachypnea crackles cyanosis cool/clammy skin pallor diaphoresis weak peripheral pulses delayed cap refill decreased UO anxiety/confusion/agita tion
  4. What is Hypovolemic Shock?: Loss of fluid volume (hemorrhage, vomiting, burns, etc) that results in decreased preload, CO, tissue perfusion
  5. What are the CM of Hypovolemic Shock?: hypotension tachycardia decreased UO (2nd) anxiety (1st)
  6. What is Neurogenic Shock?: Hemodynamic response to T5 or above spinal injury that causes massive vasodilation and decreased perfusion.
  7. What are the CM of Neurogenic Shock?: hypotension BRADYCARDIA poikilothermia
  8. What is Anaphylactic Shock?: Hypersenitivity rxn resulting in massive

wheezing/ stridor flushing pruritus hives angioede ma

  1. What is Septic Shock?: Systemic infection causing vasodilation and increased cap permeability that results in hypotension despite fluids and inadequate tissue perfusion.
  2. What are the CM of Septic Shock?: hypotension hyperventilation respiratory failure altered neuro decreased UO
  3. What is Obstructive Shock?: Physical obstruction to blood flow (cardiac tam- ponade, pneumothorax, PE, etc) decreases CO.
  4. What are CM of Obstructive Shock?: S/S of decreased CO JVD
  5. What is the priority nursing care for Shock?: Oxygenation & Ventilation (patent airway, deliver O2)
  6. How do you Evaluate Shock Tx?: baseline VS ECG normal sinus BP 80- CVP 2- PAWP 6- normal temp warm, dry skin UO 30 ml/hr normal RR SPO

90%

  1. What is emergency care for Shock?: assess ABCs stabilize spine administer O est. IV access begin fluids

(NS) draw labs control bleeding assess injuries vasopressors if hypotension persists insert catheter

incentive spirometry hydration humidification chest PT suctioning ambulation HOB elevated tripod positioning

administer bronchodilators administer corticosteroids administer diuretics treat PNU reduce anxiety & pain high calorie, high protein diet

  1. What are the CM of ARDS?: decreased SPO2 despite oxygenation severe dyspnea tachypnea intercostal/suprasternal retractions diaphoresis change LOC cyanosis pallor hypercapn ea
  2. What is Nursing Care for ARDS?: O admin PEEP prone positioning monitor hemodynamics monitor daily weights monitor I&O administer vasopressors, diuretics, IV fluid, sedation/analgesia
  3. Safety Alert: Sedation/Anagesia: monitor for CNS depression assess agitation and tx cause may cause delayed weaning from mechanical vent. provide concurrent sedation & analgesia to the point of unconsciousness for receiv- ing neuromuscular blockade (paralysis) use neuromuscular blockade for shortest & lowest dose
  4. What is nursing care for A Fib?: drugs for HR (diltiazem, metoprolol, digoxin) antidysrythmics (amiodaraone) anticoagulants (warfarin)
  5. What is nursing care for V Tach?: pulse = antidysrhythmics (amiodaraone) CPR
  1. What are the different Oncologic Emergencies?: 1. Superior Vena Cava Syndrome 2.Spinal Cord Compression 3.Third Spacing 4.Hypercalcemia 5.Tumor Lysis Syndrome 6.DIC 7.Sepsis
  2. What is Superior Vena Cava Syndrome?: Obstruction of Superior Vena Cava facial edema distention of veins in head, neck, face, chest HA seizures
  3. What is Tx for Superior Vena Cava Syndrome?: Raditation or chemo therapy
  4. What is Spinal Cord Compression?: neurologic emergency persistent, localized back pain motor weakness paresthesia sensory loss change in bladder or bowel
  5. What is Spinal Cord Compression Tx?: radiation corticosteroids surgical decompression
  6. What is Third Spacing?: Shift of fluid from vascular to interstitial space hypovolemia hypotension tachycardia decreased UO
  7. What is Tx for Third Spacing?: fluid, electrolyte, plasma protein (albumin) replacement during recovery: reduce fluids and monitor balance
  8. What is Hypercalcemia?: cx secretes parathyroid-like hormone apathy depressio n fatigue muscle

weakness dysrhythmias polyuria/noctur ia anorexia